Evidence-based Chiropractic II

Evidence-based Chiropractic II • Michael T. Haneline, DC, MPH • michael.haneline@palmer.edu • http://w3.palmer.edu/michael.haneline • PP presentations • Articles and checklists for class workshops • Sample test questions • Syllabus, etc. Evidence-based Chiropractic

Evidence-based Chiropractic II • Required text: • Evidence-based Chiropractic Practice. Haneline M. Jones & Bartlett Publishers • Read chapters before pertinent class sessions • Exam questions are taken from the text Evidence-based Chiropractic

Syllabus • Topics • Elementary biostatistics • Research design • Literature searching strategies • Outcome measures and the importance of their use in a chiropractic practice • Class workshops appraising several articles • Literature searching workshop in the library Evidence-based Chiropractic

Course Goals • To assist students in becoming critical thinkers in chiropractic practice • To teach students to find, acquire, read, critically appraise, understand and apply information published in scholarly periodicals • To relate research to clinical practice and clinical practice to scholarship Evidence-based Chiropractic

Projects • Case Report Critical Appraisal • Literature Review Critical Appraisal • Reliability of Outcome Measures Critical Appraisal • Randomized Clinical Trial Critical Appraisal • EBC 5-step project Evidence-based Chiropractic

Evidence-based Chiropractic Practice The best available research evidence, combined with clinical expertise and patient values.

What is Evidence-based Chiropractic (EBC)? • EBC developed out of a movement started by a group of medical educators at McMaster’s University during the 1980s • These physicians observed that a gap had developed between what occurred in clinical practice and what was obtainable in reports of clinical research Evidence-based Chiropractic

What is EBC? (cont.) • Essentially, clinicians could not stay abreast with new research because it was being produced so fast; consequently they were not putting into practice the most current information • Evidence-based methods were designed to bridge this gap Evidence-based Chiropractic

What is EBC? (cont.) • Originally known as evidence-based medicine (EBM) • The concept has been embraced by thechiropractic profession (and others) Evidence-based Chiropractic

EBC is unique in several ways • Chiropractic interventions (manipulation) are difficult to investigate by experimental methods • Difficulty in designing an effective placebo • It is difficult to blind both doctors and patients • As a result, there are fewer chiropractic articles that use a placebo control group than other disciplines Evidence-based Chiropractic

EBC is unique (cont.) • Chiropractors commonly utilize multiple treatment modalities • A variety of manipulations, exercises, ergonomic advice, physiotherapy, etc. • In contrast, clinical trials often utilize only one modality • In order to isolate it and compare it with a placebo or an alternative therapy Evidence-based Chiropractic

EBC is unique (cont.) • Finances were very limited for chiropractic research in the past which hampered progress • High-quality research is very expensive • Things have changed in recent years • Federal funds are increasingly becoming available • Numerous elegant chiropractic studies have resulted Evidence-based Chiropractic

A unique evidence base • The uniqueness of chiropractic research has produced a correspondingly unique evidence base of chiropractic information • Studies may appear to be less rigorous than for other forms of treatment • Nonetheless, many studies are available to support and help direct chiropractic patient care Evidence-based Chiropractic

Evidence-based practice (EBP) is • “. . . the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” David Sackett, MD Evidence-based Chiropractic

EBP incorporates the skills of the doctor • The practitioner’s clinical expertise is integrated with the best available external clinical evidence from systematic research • Clinical expertise: the skills and knowledge gained by clinicians through clinical experience and practice • EBP relies heavily upon the practitioner’s past clinical experience Evidence-based Chiropractic

EBP is not a “cookbook” method of practice • It is the integration of the best evidence with the past training and expertise of the clinician, which results in better care for the patients • Evidence is added to patient care to replace outdated information Evidence-based Chiropractic

Patient preferences • The personal values, concerns, and expectations that patients have about their care • Taking patient preferences into consideration is an essential step in the EBP process Evidence-based Chiropractic

Patient preferences (cont.) • Personal values • The beliefs patients have about the care that is being offered to them • May be related to philosophical or even religious issues • Patient concerns • e.g., financial issues, time constraints, and office location Evidence-based Chiropractic

Patient preferences (cont.) • Patient expectations • The degree that patients accept a doctor’s recommendations • Often wide-ranging and can have a significant impact on clinical results Evidence-based Chiropractic

EBC is . . . • Actively seeking support for and improvement of chiropractic clinical practice through the integration of the best available research evidence, combined with clinical expertise and patient values. Evidence-based Chiropractic

EBC is . . . Evidence-based Chiropractic

Why EBP? • Practitioners may not have enough information to answer clinical questions • Complicated cases • Patients sometimes ask difficult questions • The need to stay current in light of an overwhelming amount of new research • Must be able to distinguish the good from the bad Evidence-based Chiropractic

Why EBP? (cont.) • Best practices • Use of the most valid clinical tools available • Established through research • To determine the most effective form of treatment • Is there any associated harm? • Utilize valid and reliable diagnostic tests Evidence-based Chiropractic

Why EBP? (cont.) • Better reimbursement • Insurance companies often pay for services when provided with an explanation grounded in credible evidence that justifies the clinical procedures Evidence-based Chiropractic

When EBP? • Patient-specific • Patients who present for care with unusual conditions that are unknown to the practitioner • Is the patient a good candidate for chiropractic care? • What are the best case management options? • Are there contraindications to manipulation? • Should the patient be referred elsewhere? Evidence-based Chiropractic

When EBP? (cont.) • Condition-specific • Practitioners become familiar with unknown conditions • After the patient presents for care • Reactive learning • Before the patient presents for care • Proactive learning • Achieved by consistently reading current evidence Evidence-based Chiropractic

When EBP? (cont.) • Self education • Attending seminars and conferences • How informed is the speaker and how accurate and current is the material? • Practitioners gathering the best available evidence on their own • Journal articles are the most dependable source • Textbooks and prior knowledge become obsolete rapidly as new information becomes available Evidence-based Chiropractic

It takes time and practice to learn EBP methods • Some elements of EBP are difficult to master (e.g., research methods and biostatistics) • Make time to read journal articles • Peruse abstracts, then read the entire articles of those that are of interest • Set aside time to search for answers to clinical questions Evidence-based Chiropractic

The five steps of EBP • Ask a clinically relevant question • Search the literature to find the best available evidence to answer your question • Appraise the evidence for validity and applicability to the clinical circumstances • Apply the relevant evidence to the clinical situation • Evaluate your effectiveness in carrying out steps 1 through 4 and revise if necessary Evidence-based Chiropractic

Asking clinical questions • Question should be clinically relevant • The answer will help with the management of a particular patient or patients with a similar condition • A good question will help guide the search for evidence toward relevant material • Can save a great deal of time Evidence-based Chiropractic

Two types of questions • Background questions • Simple two-part questions that address the basic facts about a patient’s health problem • Do not fully address issues about the best diagnostic or treatment options • This type of information can be acquired from current textbooks and peer-reviewed and referenced electronic publications (e.g., Harrison’s Online) • http://www.merckmedicus.com Evidence-based Chiropractic

Types of questions (cont.) • Foreground questions • More complex than background questions • Apply to decisions about the most favorable treatment or diagnostic strategies • Derived from • Primary sources (journal articles of clinical studies) • Secondary sources (expert reviews of all available original articles on a given topic) Evidence-based Chiropractic

Elements of a good clinical question (PICO) • Patient or problem • Intervention • Comparison intervention (optional) • Outcome(s) of interest • Should be of interest to patients (e.g., less pain or disability) Evidence-based Chiropractic

PICO example • Is manipulation effective at reducing back and leg pain in a middle aged female patient with lumbar spinal stenosis and concomitant radicular pain, or are any alternative methods more favorable? • A middle aged female patient with lumbar spinal stenosis and concomitant radicular pain • Manipulation • Any alternative method that might be superior to manipulation • A reduction of lower back and leg pain Evidence-based Chiropractic

Patient-Oriented Evidence that Matters (POEMs) • The outcome in a study should be something patients care about • Like morbidity or quality of life • The problem should be widespread and the intervention should be feasible • The information should have the potential to change the practice of many practitioners Evidence-based Chiropractic

Disease Oriented Evidence (DOE) • Studies that involve outcomes that may be of interest to researchers and practitioners, but are of little interest to patients • Surrogate end points are used as a substitute for clinically meaningful POEMs • Examples: range of motion, leg length Evidence-based Chiropractic

Example of a POEM • A RCT showing that exercise along with manipulation leads to less low back pain and disability than manipulation alone • Why? • Problem is encountered frequently in practice • The article considers pain, and disability as the primary outcomes (patient oriented) • This should be a “practice-changer” for chiropractors who use manipulation only Evidence-based Chiropractic

What is evidence? • Something that is helpful in forming a conclusion or judgment • Found primarily in journal articles that deal with: • The effectiveness and safety of treatments • The validity and reliability of diagnostic tests • The incidence and prevalence of diseases in populations Evidence-based Chiropractic

Hierarchy of research evidence Progressively fewer studies are available as one advances from the lowest to the highest levels of the evidence pyramid Systematic reviews of RCTs are considered by most to be the “gold standard” for determining if a treatment is effective Use the highest level of evidence possible to make clinical decisions Evidence-based Chiropractic

Progression of clinical investigation • Clinical investigation typically begins with case reports/series, then advances to observational studies, and then to RCTs • The final step is a systematic review after a few RCTs have been reported Evidence-based Chiropractic

A lower-level study may be better evidence • Studies that rank higher on the hierarchy of evidence pyramid are not always better • For instance, a single RCT that involved few subjects is not necessarily more credible than reliable results from a high-quality non-randomized trail • Sometimes RCTs are of little value because of design flaws Evidence-based Chiropractic

Evidence in EBP is founded on science • Science is . . . • The observation, identification, description, experimental investigation, and theoretical explanation of phenomena Evidence-based Chiropractic

Founded on science (cont.) • The scientific method • The principles and empirical processes of discovery and demonstration considered characteristic of or necessary for scientific investigation, generally involving the observation of phenomena, the formulation of a hypothesis concerning the phenomena, experimentation to demonstrate the truth or falseness of the hypothesis, and a conclusion that validates or modifies the hypothesis Evidence-based Chiropractic

Practitioners should be able to interpret scientific reports • Must be able to discriminate good- from poor-quality evidence • Unfortunately, many do not understand basic research methods • This state of affairs is changing • Continuing education for practitioners • Chiropractic students are now taught to interpret scientific reports Evidence-based Chiropractic

Evidence rating systems • Used to rate the quality and class structure of evidence • Examples • Scottish Intercollegiate Guidelines Network (SIGN) • Agency for Healthcare Research (AHRQ) • Oxford Centre for Evidence-based Medicine (CEBM) Evidence-based Chiropractic

Rating systems (cont.) • The relative strength of evidence depends on: • Position in the hierarchy of study designs • The study’s validity • Refers to the degree that a study design is able to produce dependable results Evidence-based Chiropractic

SIGN levels of evidence • 1++ • High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias • 1+ • Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias • 1− • Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias Evidence-based Chiropractic

SIGN levels of evidence (cont.) • 2++ • High quality systematic reviews of case-control or cohort studies or High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal • 2+ • Well conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal • 2− • Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal Evidence-based Chiropractic

SIGN levels of evidence (cont.) • 3 • Non-analytic studies (e.g., case reports, case series) • 4 • Expert opinion Evidence-based Chiropractic

Grades of recommendations • Utilized by guidelines developers to make comments about the appropriateness of various treatment and diagnostic procedures • Recommendations are based on the quantity and quality of evidence that is available Evidence-based Chiropractic

Evidence-based Chiropractic II